Dean's Update
February 18, 2022 - Aron Sousa, MD
Friends,
This week I had the pleasure of attending an initial meeting of Henry Ford’s Primary Care Research Institute (PCRI). An august group of researchers, primary care leaders, and Henry Ford chairs, including our own chair, Rick Leach, MD, met to think about how to do more research on primary care questions. Investigating research questions in a primary care setting requires a multidisciplinary team who can handle social determinants of health, manage multiple clinical partners, analyze the data, and deliver the medical care. A great example of this kind of work is Dr. Ade Olomu’s Office-GAP program (Office Guidelines Applied in Practice). In her NIH-funded work, Dr. Olomu creates and tests systems of care to improve the health of patients with diabetes and cardiovascular disease. I am excited by the possibilities of the PCRI as MSU and Henry Ford work together more closely.
Some of the more common questions in primary care research circle around who is at risk of poor outcomes and algorithm-based care. It can make a lot of sense to use formulas and preset rules to screen populations for disease risk or treatment benefit, so you can target communication to those most likely to benefit from diagnostic or treatment interventions. That sounds great until you find out that some of our data and formulas suffer from systemic bias. The largest concern comes from “race-based norming,“ which in the best cases tries to statistically adjust for previous societal racism, but it really just “normalizes” racism into statistics. No one means for this to happen. It might even seem overtly sensible to just let rules fall out of the data; but data do not have wisdom, and data do not know what folks it is missing.
Each week during Black History Month, I try to highlight our work and suggest a topic that might trigger some curiosity. For this week, I was thinking about the work of Duke surgeon, Lisa McElroy, MD, (CHM ’09) and her study of how abdominal transplant rules systematically disadvantage minoritized populations. These rules can seem reasonable, but they are really changing access to health in a way that is a form of racial norming.
Many of the problems with racial norming become obvious in various kinds of performance testing, as evidenced in the NFL concussion settlement debacle. There is long history of using race in calculations of medical risk even though race is a social rather than biological construct. When people self-report their race in a study, they are generally following the social construct of race rather than some biological understanding of genetics. And many of these studies do not have adequate representation of Blacks and other minoritized populations.
The NEJM has a helpful table that summarizes problematic “racial corrections” in clinical rules and calculations. Each calculation has a clear equity concern. For example, the calculation for kidney function has modifying terms for sex and race and both have been updated (and reduced) with better population representation. And, it could still be that these modifiers meaningfully delay diagnosis or limit access to care for Black people. The table is pretty interesting reading.
At an important level, this gets to how we ask questions. Asking about race is not the same as asking about genetics or family history. As a thought experiment, imagine choosing not to ask about race but rather asking if someone is exposed to racism. Wouldn’t that change how we think about how social constructs get incorporated into these calculations? As a profession, we have a lot of work to do to ensure we are not baking bias and racism into our clinical calculations and prediction rules.
But wait, there is more! I encourage you to watch WOOD TV8’s “Being Black in a White Coat” a wonderful piece that speaks to our college’s initiatives to increase diversity in medicine. The three women featured are at different stages of their careers and include Dr. Wanda Lipscomb, Dr. Candace Smith-King (CHM ’03) and resident Dr. Elexus-Ember Carroll.
I do not think most of us would have predicted that in two years of pandemic the excess deaths would include 1,000,000 Americans. From 2019 to 2020 there was a nearly 20% jump in dead Americans from 2.8 million to 3.3 million deaths per year. Most of those people died as a direct result of COVID-19, but many of them died of other causes made worse by the disturbances and displacement of the pandemic. Add to that million the larger number of people whose lives have been irreversibly changed by severe illness. That is so many bereaved families, friends, neighbors. And, those are our families, friends, and neighbors.
In the years of the pandemic, the people of the College of Human Medicine have spanned the roles of the entire response to COVD-19. Our faculty, staff, and students across the state have cared for the sick and their families; they have organized community vaccinations, blood drives, and food deliveries; they have created tests and tested vaccines; and they have trained the workforce we so desperately need to do a better job in the future.
Since the 1980s, I do not think there is a person in the college who has done more to train the physicians of the future than Dianne Wagner, MD. Over parts of many decades, Dr. Wagner has cared for thousands of patients and has been recognized by colleagues as one of the best internists in the city. She has run clinical skills, graduate medical education, undergraduate medical education, problem-based learning, college-wide assessment, and the only citywide medical safety program Lansing has ever had. She has been a national leader in medical education, been our senior associate dean for academic affairs, implemented our new curriculum, helped create the first standardized patient programs in the country, and has played a key role in the education of about 4,000 physicians – that’s more than half of the college’s alumni.
Dianne has announced her retirement date of June 1, 2022, and she deserves to do whatever she wants to do. I met Dianne in late 1999 at a Division of General Internal Medicine retreat held at her house, and, if memory serves, the first thing I did was insult the sharpness of her knives. From that inauspicious beginning, we spent almost 20 years as clinic buddies practicing medicine next to each other, asking each other questions, discussing our lives, kibitzing about medical education, and taking each other to see our patient’s rashes for a second opinion. For those of you have had a clinic buddy, you will understand that partnership; and for the rest of you, I hope you get to have that kind of trusting relationship with a colleague. I could go on and on, but most of you already know her, her outstanding sense of humor and wit, her ability to write a song in celebration of any occasion, her intelligence, and her principle-based approach to any challenge. She is not going anywhere for a while, but our college will have to make some decisions in the nearer term. In the meantime, give her a shout-out and a thank you for all she has done for patients, the college, and the profession – truly serving the people.
Serving the people with you, Dianne,
Aron
Aron Sousa, MD
Interim Dean